0920-XXXX GenIC Proposal
Date:
Name, CIO/Program:
Cooperative Agreement:
Provide the number and name of the
cooperative agreement whose awardees will be asked to fill the
form(s).
Purpose of Form(s): Describe the purpose of the forms for which you seek approval, e.g., work plan, evaluation, success story.
Use of Data: Explain how data will be assessed and used by CDC.
Personally Identifiable Information (PII): If PII will be collected, describe the PII elements and the methods that will be used to ensure participant privacy, and state whether the PII will be stored and used a way subject to the Privacy Act of 1974.
Respondents:
Provide a list of the
respondents (names of awardee organizations) here or attach an
additional page. If the form(s) must be filled by particular roles
within awardee organizations, e.g., Chief Medical Officer, CFO,
specify that here.
Collection Frequency and Timeline: Describe how often the form(s) will be used and when.
Collection Method: State how the information will be provided to CDC, e.g., email or a particular online system.
Annual Burden Table: Complete the burden table here, adding or deleting rows as needed. Use 1 row for each form and provide average annual numbers.
Type of Respondents |
Type of Form |
Number of Respondents |
Number of Responses per Respondent per Year |
Average Burden per Response (in hours) |
Total Burden (in hours) |
Cooperative Agreement Recipients |
Must match item 4 above |
Number must match list in item 7 above. |
Calculation must match information given in item 8 above. |
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Multiply number of respondents x number of responses in one year x number of hours per response |
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Total |
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Please include all data collection forms when you submit this document.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Still-LeMelle, Terri (CDC/DDNID/NCCDPHP/OD) |
| File Modified | 0000-00-00 |
| File Created | 2024-07-20 |